The continuing nursing education pattern included hospital training (77.0%), distance education (62.0%), academic conferences (32.0%) and self-study (27.0%). The continuing education contents involved new basic theoretic knowledge (71.5%), new nursing techniques (62.0%), nursing safety (56.0%), health education (47.5%), nursing teaching (36.0%), and nursing management (34.5%). In the efficacy of continuing nursing education, 67.8%, 30.2% and 2.0% nurses felt satisfactory, acceptable and unsatisfactory, respectively. The reasons for no or rare participation in the continuing education were busy work (54.8%), rigid pattern (21.7%), high costs (20.7%), and quota limit (10.1%). The details are shown in Table 1.

In the investigated nurses from the gross-root medical institutions, 20.6% never had received continuing nursing education, of which 96.2% were aged ≤ 35 years, 82.7% had ≤ junior college education, and all had professional titles of ≤ senior nurse.

With continuing education participation in the past three years as grouping variable, the following factors were included into the statistical analysis: work unit, sex, age, professional title, post, education, organizational affiliation, unit support, and hospital policies (Table 2). The factors related with the continuing education participation in the past three years were work unit (p = 0.004), organizational affiliation (p < 0.001), age (p < 0.001) and professional title (p < 0.001). It indicated that more nurses working in the community health service centers and with a bigger age, a higher professional title and “established” organizational affiliation participated in the continuing nursing education.

The setting of variables was same as the above, i.e., work unit (community health service center, OR = 0.09, p < 0.001; reference variable: township hospital), organizational affiliation (established, OR = 0.02, p < 0.001; reference variable: Bachelor education), and hospital polices (p = 0.008; reference variable: satisfactory). The results are shown in Table 3. This further indicated that more nurses working in the community health service centers, with “established” organizational affiliation and who had higher satisfaction to hospital policies participated in the continuing education.

The demographic data showed that the grass-root nurse team were young and had low professional titles and low education, which is consistent with the study results of Fu Lili and Chen Shengyu et al. [4]. The continuing education pattern was mainly hospital training and distance education, because they were more convenient than academic conferences, advanced education and other resource acquisition channels, required less time and low costs, and were easier for units to organize and implement. The continuing education contents focused on new basic theoretic knowledge, new nursing techniques and nursing safety, maybe because most grass-root nurses had ≤ junior college education and ≤junior professional titles. The nurses had low satisfaction to the efficacy of continuing education, and only 2/3 of them felt satisfactory, which is lower than the study results of Miao Maoyun and Zhang Xiangfeng et al. [5]; the possible reason is that the grass-root medical institutions provide few standard and systematic nurse training platforms and channels for nurses [6]. Based on the survey results,

a half of nurses failed to participate or rarely participated in the continuing education because of busy work, and 1/5 nurses complained about rigid pattern and high costs, which is similar to the study results of Li Shujin and Tang Wenguo et al. [7]. It indicates that when carrying out the continuing education activities, the relevant organization departments (e.g., hospitals) shall fully combine the actual clinical work situation, adopt more flexible course teaching modes, consider the limited learning time of nurses, and provide fund assurance to improve the participation and satisfaction of continuing education.

As shown by the survey, 1/5 grass-root nurses never had received continuing nursing education in the past three years, and their demographic data indicated that over 90% were aged ≤ 35 years and had ≤ junior professional titles, they were the young strength of the grass-root nurse team, and their professional quality was closely associated with the overall service level of grass-root nurses [8]. These nurses become the population to be forgotten when the continuing education activities are carried out, so the organizations shall pay importance and actively take measures to eliminate the “blind zone”. The factors influencing the continuing education participation included work unit, age, professional title, organizational affiliation and satisfaction to hospital policies. All 5 community health service centers were all in the county urban area and had a bigger distance advantage than township hospitals in obtaining the continuing education resources from the district people’s hospital and other superior hospitals; meanwhile, their service objects were more than those of township hospitals, which gives stronger external motivation of learning to the nurses [9]; thus, compared with township hospitals, more nurses working in the community health service centers participated in the continuing education activities. Furthermore, the nurses with high professional titles had a higher professional foundation and higher self-orientation [10], and most of them were paid importance in cultivation by the hospitals and leaders together with the established nurses; thus, these nurses had more chances to participate in the continuing education. In the satisfaction to hospital policies, higher continuing education participation initiative of nurses depends on more importance to the capability promotion of nurses, more support to the continuing education participation of nurses, and more excellent incentive measures from the hospitals. It is easily seen that the work unit, age, professional title and organizational affiliation are relatively fixed and difficultly changed in a short time, while the hospital policy measures can be conveniently taken to influence the continuing education participation of grass-root nurses. Therefore, the leadership can fully consider the influence of the nurse team during the policy development process to encourage the continuing education behaviors.

Since the implementation of new medical reform, the grass-root nurses bear heavy work and their nursing scope is gradually enlarged, while insufficient human resources restrict the promotion of nursing service level and the participation of continuing education to a certain degree [12]. Therefore, the leadership shall fully consider the demand, enrich the human resources of grass-root nurses, optimize the post configuration, and reduce the waste of human recourses; meanwhile, the leadership shall provide more learning convenience for nurses under the current conditions by flexible shift arrangement and learning time supplementation to increase the continuing education participation.

Despite an awareness of the importance of continuing nursing education, the grass-root management departments fail to establish the systematic and standard continuing education procedures, and there are different assessment systems in various regions [13]. Partial nurses only participate in the continuing education for getting credits, and it is suggested that the competent units complete the continuing education training system of grass-root nurses and realize the urban-township equal and homogenous training modes and assessment systems. In addition, these units are suggested to enlarge the incentive strength to provide reimbursement for learning funds and promotion chances for encouraging the active participation of nurses, thus achieving the full coverage of continuing education and maximizing the utilization and stabilization of the current grass-root nurse team.

The development of Internet offers a new possibility of learning. The studies have shown that Internet-based learning can enhance the training efficacy and has such advantages as no geographic limitation, effective realization of training resource sharing, and training time saving [14] [15] [16]. The relevant departments shall actively explore the training modes meeting the demand of the times, positively make a response to “Internet + nursing”, and create a “digital and mobile” ubiquitous learning platform and resources to be accessed at any time and at any place by such means as remote network, teleconference, CD-ROM, WeChat, QQ group and app [17] [18], so that the nurses have no worries about the training quota, traveling time and funds and can make full use of fragmented time, thus eliminating the work-learning conflict and realizing the purpose of training without “a long trip”.

The demand of nurses for continuing education contents in this study was in a primary stage but demonstrated diversity, perhaps because the work scope of nurses in the grass-root medical institutions gradually extended to the prevention of chronic diseases, geriatric nursing, health education, prevention and health care, and psychological nursing. The leadership departments shall pay importance to the learning demand of nurses, work out the training contents with such demand as guidance, increase the fund input of open learning resources, break through the task-based learning thinking of “non-conformance with the actual work” and “learning just for learning”, and practice the continuing nursing education using several education patterns to really promote the overall quality of grass-root nurses.